INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
■
A r r
e
Y
■ o u R
e
a
d y t t o
A
u
d i i t t ?
■
■
In order to complete the auditing process successfully, all three of these auditing components must be performed during the auditing process
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 1

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
Location: __________________________
Time: ______hours / ____AM ____PM
Auditor (print): _______________________
Date: YYYY_______ MM_______ DD_______
Manager: _____________________________
Signature: ____________________________
NOTE: For instructions for removing items of personal protective equipment, refer to Annex A and to website links at: http://www.chica.org/AuditToolkit/tools_toolsTOC.html
.
Coding Key:
HEALTH CARE WORKER (HCW) TYPE:
1 = Physician/Medical Student
2 = Nursing/Nursing Support
3 = Social Work
4 = Pastoral Care
5 = IV team
6 = Dietitian
TYPE OF PRECAUTIONS:
A = Airborne Precautions
C = Contact Precautions
D = Droplet Precautions
Y
Abbreviations:
AP
HCW
Additional Precautions
Health Care Worker
N
N/A
PPE
RP
No
Not Applicable
Personal Protective Equipment
Routine Practices
Yes
7 = Physiotherapist/Occupational Therapist
8 = Environmental Services Worker
9 = Patient Transporter
10 = Radiology Technologist
11 = Respiratory Therapist
12 = Other
AC = Airborne + Contact Precautions
AP = Additional Precautions
DC = Droplet + Contact Precautions
RP = Routine Practices
Revised May 18, 2010
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 2

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
Glossary:
Additional Precautions (AP): The precautions (i.e., Contact Precautions, Droplet Precautions, Airborne
Precautions) that are necessary in addition to Routine Practices for certain pathogens or clinical presentations. These precautions are based on the method of transmission (e.g., contact, droplet, airborne).
Airborne Infection Isolation Room: A room that has engineering controls in place consistent with standards from the Canadian Standards Association (CSA).
Airborne Precautions: Precautions that are used in addition to Routine Practices for clients/patients/residents known or suspected of having an illness transmitted by the airborne route (i.e., by small droplet nuclei that remain suspended in the air and may be inhaled by others).
Contact Precautions: Precautions that are used in addition to Routine Practices to reduce the risk of transmitting infectious agents via contact with an infectious person and/or the environment.
Droplet Precautions: Precautions that are used in addition to Routine Practices for clients/patients/residents known or suspected of having an infection that can be transmitted by large infectious droplets.
Fit-Test: A qualitative or quantitative method to evaluate the fit of a specific make, model and size of respirator on an individual. Fit-testing is to be done periodically, at least every two years and whenever there is a change in respirator face piece or the user’s physical condition which could affect the respirator fit.
Hand Hygiene: A general term referring to any action of hand cleaning. Hand hygiene relates to the removal of visible soil and removal or killing of transient microorganisms from the hands. Hand hygiene may be accomplished using soap and running water or an alcohol-based hand rub.
Hand hygiene includes surgical hand antisepsis.
N95 Respirator: A personal protective device that is worn on the face and covers the nose and mouth to reduce the wearer’s risk of inhaling airborne particles. A NIOSH-certified N95 respirator filters particles one micron in size, has 95% filter efficiency and provides a tight facial seal with less than 10% leak.
Personal Protective Equipment (PPE): Clothing or equipment worn by staff for protection against hazards.
Routine Practices (RP): The system of infection prevention and control practices recommended by the
Public Health Agency of Canada to be used with all clients/patients/residents during all care to prevent and control transmission of microorganisms in all health care settings.
Seal-Check: A procedure that the health care provider must perform each time an N95 respirator is worn to ensure it fits the wearer’s face correctly to provide adequate respiratory protection. The health care provider is to receive training on how to perform a seal-check correctly.
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 3

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
NOTE: See the Table of Contents for additional audit tools that expand on individual elements of these audit tools (e.g., Hand Hygiene, Routine Practices, Environmental Cleaning)
Health Care Worker
Bed/Bed Space Location or Number ►
Type of Precautions ( see list of types p.1
) ►
Type of Health Care Worker ( see list of types p.1
) ►
Element/Item to be Monitored: ▼
1.0 Policies and Procedures
1.1 Personal protective equipment (PPE) supplies are readily available and easily accessible in a variety of sizes
1.2 There are policies and procedures for Routine
Practices (RP) and Additional Precautions (AP) that include the use of PPE
2.0 Putting On PPE
2.1 Hand hygiene is performed before putting on
PPE
2.2 PPE are worn as single-use items for each clinical procedure or episode of care and are removed prior to leaving client/patient/resident room or care area
3.0 Gown
3.1 Gown is worn as indicated by RP or AP
3.2
3.3
Appropriate size and type of gown is selected
Gown is securely tied at the neck, waist and at the back
3.4 Gown is not worn outside of patient room/area
4.0 Mask With/Without Attached Eye Protection
4.1
4.2
Mask is worn as indicated by RP or AP
Mask is placed over nose, mouth and chin
4.3
4.4
5.1
Flexible nose piece fits over nose bridge
Mask is secured on head with ties or ear loops
4.5 Mask has been adjusted to fit securely
5.0 N95 Respirator
The health care worker (HCW) has been fittested
5.2
5.3
5.4
5.5
N95 respirator is worn as indicated by AP
N95 respirator is selected based on prior fittesting
N95 respirator is placed over nose, mouth and chin
Flexible nose piece fits over nose bridge
Compliance (Y, N, N/A): ▼
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 4

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
Bed/Bed Space Location or Number ►
Health Care Worker
Type of Precautions ( see list of types p.1
) ►
Type of Health Care Worker ( see list of types p.1
) ►
Element/Item to be Monitored: ▼ Compliance (Y, N, N/A): ▼
5.6
5.7
N95 respirator is secured on head with top elastic followed by bottom elastic
The HCW can perform a seal-check (respirator collapses on inhale, does not leak on exhale)
5.8
5.9
N95 respirator is discarded after use (not reused)
Hand hygiene is performed after removing N95 respirator
6.0 Eye Protection (unless using mask with attached eye protection)
6.1
6.2
6.3
6.4
6.5
Eye protection is worn as indicated by RP or AP
Goggles are positioned over eyes and secured to the head using the ear pieces or headband
Face shield is positioned over the face and secured at the brow with head band
Eye protection is adjusted to fit comfortably
Re-usable goggles are cleaned after each use
7.0 Gloves
7.1 Gloves are worn as indicated by RP or AP
7.2 Gloves fit well and are of sufficient durability for the task
7.3 Single-use, disposable gloves are not re-used or washed
7.4
7.5
7.6
7.7
Gloves are put on immediately before contact with a client/patient/resident, when appropriate
Hands are cleaned before putting on and after taking off gloves
Gloves are put on last (if gown and facial protection are worn)
The correct length, type and size of gloves are selected
7.8 Gloves extend over cuffs of gown, if worn
8.0 Safe Use of PPE
8.1
8.2
8.3
8.4
Gloved hands are kept away from the face
Once the task is underway, PPE is not touched or adjusted
Gloves are removed if they become torn or as required during a long procedure; hand hygiene is performed before putting on new gloves
Items and surfaces in the room are not touched with gloved hands unless necessary
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 5

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
Bed/Bed Space Location or Number ►
Health Care Worker
Type of Precautions ( see list of types p.1
) ►
Type of Health Care Worker ( see list of types p.1
) ►
Element/Item to be Monitored: ▼ Compliance (Y, N, N/A): ▼
9.0 Taking off PPE
9.1
9.2
9.3
9.4
PPE is removed as soon as the activity is completed
PPE should be removed in a manner that avoids contamination
PPE is removed in sequence: gloves gown hand hygiene eye protection mask/respirator hand hygiene
If the client/patient/resident is on AP, PPE is removed at the doorway before leaving the room, or in the anteroom (if available)
9.5 For airborne infection isolation rooms, the N95 respirator is removed outside the room, after the door has been closed
Compliance Score
Total number of ‘Yes’
Total number of ‘No’
Total number of items (‘Yes’ and ‘No’, exclude ‘N/A’)
Compliance Score (see below for calculation):
Scoring:
Total number of ‘yes’
________________________ x 100 = % compliance (compliance score)
Total number of ‘yes’ and ‘no’
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 6

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
Feedback on Compliance:
There is a process in place to address audit deficiencies and to provide timely feedback, on a priority basis (e.g., safety issues would be addressed immediately).
Additional Comments:
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 7

INFECTION PREVENTION AND CONTROL AUDIT for
Use of Personal Protective Equipment (PPE)
References:
1. Public Health Agency of Canada. Routine Practices and Additional Precautions for
Preventing the Transmission of Infection in Health Care . Can Commun Dis Report. 1999: 25
Suppl. 4:1-142. Available online at: http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/99vol25/25s4/index.html
.
2. Public Health Agency of Canada. Prevention and control of occupational infections in health care. Can Commun Dis Rep. 2002; 28 Suppl1:1-264. Available online at: http://www.phacaspc.gc.ca/publicat/ccdr-rmtc/02vol28/28s1/index.html
.
3. Ontario Ministry of Health and Long-Term Care.
Just Clean Your Hands Program (2008) .
Available online at: http://www.justcleanyourhands.ca
.
4. Ontario Ministry of Health and Long-Term Care. Provincial Infectious Diseases Advisory
Committee. Routine Practices and Additional Precautions in All Health Care Settings
August, 2009. Available from: http://www.health.gov.on.ca/english/providers/program/infectious/diseases/ic_routine.html
.
.
5. Siegel J, Rhinehart E, Jackson M, Chiarello L. The Healthcare Infection Control Practices
Advisory Committee. Guideline for Isolation Precautions: Preventing Transmission of
Infectious Agents in Healthcare Settings.
Am J Infect Control 2007;35(10 [Suppl 2]):S64-164.
Available from: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
.
DISCLAIMER:
These audit tools are based on infection prevention and control best practices current at the time of publication. The individual elements provided in these tools are not intended to take the place of either the written law or regulations.
Audit Toolkit Version 2, September 2009© CHICA-Canada Page 8